• Robert Wannamaker, Taurian Guinand, Bijoy K Menon, Andrew Demchuk, Mayank Goyal, Donald Frei, Aditya Bharatha, Tudor G Jovin, Jai Shankar, Timo Krings, Blaise Baxter, Christine Holmstedt, Richard Swartz, Dar Dowlatshahi, Richard Chan, Donatella Tampieri, Hana Choe, Paul Burns, Nina Gentile, Jeremy Rempel, Ashfaq Shuaib, Brian Buck, Andrew Bivard, Michael Hill, and Kenneth Butcher.
• From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.).
• Stroke. 2018 Jun 1; 49 (6): 1426-1433.

Background And PurposeIn the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times), patients with large vessel occlusions and small infarct cores identified with computed tomography (CT)/CT angiography were randomized to endovascular therapy or standard of care. CT perfusion (CTP) was obtained in some cases but was not used to select patients. We tested the hypothesis that patients with penumbral CTP patterns have higher rates of good clinical outcome.MethodsAll CTP data acquired in ESCAPE patients were analyzed centrally using a semiautomated perfusion threshold-based approach. A penumbral pattern was defined as an infarct core <70 mL, penumbral volume >15 mL, and a total hypoperfused volume:core volume ratio of >1.8. The primary outcome was good functional outcome at 90 days (modified Rankin Scale score, 0-2).ResultsCTP was acquired in 138 of 316 ESCAPE patients. Penumbral patterns were present in 116 of 128 (90.6%) of patients with interpretable CTP data. The rate of good functional outcome in penumbral pattern patients (53 of 114; 46%) was higher than that in nonpenumbral patients (2 of 12; 17%; P=0.041). In penumbral patients, endovascular therapy increased the likelihood of a good clinical outcome (34 of 58; 57%) compared with those in the control group (19 of 58; 33%; odds ratio, 2.68; 95% confidence interval, 1.25-5.76; P=0.011). Only 3 of 12 nonpenumbral patients were randomized to the endovascular group, preventing an analysis of treatment effect.ConclusionsThe majority of patients with CTP imaging in the ESCAPE trial had penumbral patterns, which were associated with better outcomes overall. Patients with penumbra treated with endovascular therapy had the greatest odds of good functional outcome. Nonpenumbral patients were much less likely to achieve good outcomes.© 2018 American Heart Association, Inc.

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